Data Drive Revisions in PCI, STEMI Guidelines

Each of the focused updates includes detailed information about potential conflicts of interest among members of the writing committees. Individual members who appeared to have a conflict recused themselves from voting on certain sections.

Highlights of the Percutaneous Coronary Intervention Updates

1. After implantation of a drug-eluting stent (DES), dual antiplatelet therapy comprising clopidogrel and aspirin is required for at least 1 year or longer.

2. If the patient is likely to face additional surgery requiring interruption of dual antiplatelet therapy, a bare-metal stent (BMS) or balloon angioplasty with provisional stent implantation should be considered instead of a DES.

3. Between 24 hours and 28 days after a heart attack, PCI is not recommended in patients with one- or two-vessel disease and a totally occluded coronary artery if they are not hemodynamically and electrically stable and have no ongoing or easily provoked chest pain.

4. On the other hand, physicians might consider PCI for those patients or patients who respond favorably to initial fibrinolysis treatment if they don't continue to do well on drug therapy alone.

5. The balance of the evidence supports an early invasive strategy for PCI in patients with unstable angina or non-STEMI who are at moderate and higher risk.

6. In patients with STEMI, facilitated PCI with regimens other than full-dose fibrinolytic therapy may be considered in high-risk patients if PCI is not immediately available within 90 minutes and if the risk of bleeding is low.

7. In patients with STEMI, a planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful.

8. A strategy of coronary angiography with the intent to perform rescue PCI is reasonable for those patients in whom fibrinolytic therapy has failed.

9. The update includes specific guidelines for ancillary therapy in patients undergoing PCI for STEMI who received prior treatment with unfractionated heparin, enoxaparin, or fondaparinux.

10. Serum LDL cholesterol should be maintained below 100 mg/dL after PCI, and further reduction to less than 70 mg/dL is reasonable.

Source: J. Am. Coll. Cardiol. 2008;51:172–209.

Highlights of the ST-Elevation Myocardial Infarction Updates

1. As in the 2004 guidelines, the overarching goal for treatment of ST elevation myocardial infarction is that reperfusion therapy should begin within 2 hours, and ideally within 1 hour of the event.

2. The emphasis on percutaneous coronary intervention should not obscure the importance of fibrinolytic therapy.

3. With the exception of aspirin, all NSAIDs and cyclooxygenase-2 inhibitors should be discontinued immediately at the time of STEMI.

4. Early intravenous β-blocker therapy should not be given to STEMI patients who have signs of heart failure or other relative contraindications to β-blockade.

5. Long-term oral β-blockers should be used for secondary prevention in patients at high risk once they have stabilized.

6. The strategy of facilitated PCI (planned PCI immediately after administration of therapy to improve coronary patency) may be considered in subgroups of patients with a large MI or hemodynamic or electrical instability who are at low risk of bleeding.

7. Rescue PCI is suitable for patients who have received fibrinolytic therapy and who have cardiogenic shock, ventricular arrhythmia, or severe heart failure and/or pulmonary edema.

8. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for at least 48 hours and preferably for the duration of the initial hospital stay up to 8 days.

9. Clopidogrel should be added to aspirin in patients with STEMI whether or not they receive reperfusion therapy, and the clopidogrel should be continued for at least 14 days.

10. Emergency medical systems that provide advanced life support should increase the use of prehospital 12-lead electrocardiography.

Sources: J. Am. Coll. Cardiol. 2008;51:210–47